MEDICARE: BORO PARK PRIMARY MEDICAL PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1598945032
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BORO PARK PRIMARY MEDICAL PLLC

Provider Business Mailing Address
First Line	:	1153 58TH STREET
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11219
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1153 58TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11219-4526
Country	:	US
Telephone Number	:	718-431-9870
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	STUIE GOLDWASSER
Credential	:
Telephone Number	:	718-431-9870

Provider Enumeration Date	:	11/13/2007
Last Update Date	:	01/21/2014

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